gap? >> i realize it is a big challenge. at stanford, we had an interdisciplinary dialogue and issues around race. we had geneticists and other scholars trying to define the concept erased. of course, it was a heated discussion because there were different ways of approaching it. we can take race as an example for many concepts that we now use in trying to translate genetic information. one step is to have interdisciplinary dialogue. but the next step is transparency. revealing the kinds of assumptions of the different disciplines are bringing to the table, in terms of how they're defining concepts, the genetic ancestry may be very different for the geneticists than a

person in the community. may . t type of transparent language and the studies themselves in defining how they are categorizing and named their research populations. that would be a first step, i think. . . in fact, on legitimate organizations with legitimate products have not replaced -- replaced more nefarious products over the internet -- they coexist with them. we want the general population

to see the difference between the offering of this and the offering of more validated testing. you will have to address the assistance -- the existence of these things out there because they will take their rest of the field. the companies that were tested, many of them still do exist offering the same product. it has not gone away, it is just that more things have become more interesting to you. the ad to think that i think that your presentation brought up for me -- the other thing that i think your presentation brought up for me, how easy it is the sending samples for other people. it should be illegal now, whatever, but i do some counseling for a genetic testing company, and routinely when i called up to get people back their results, which we did

for genetic counselors, the person whose information says, it's actually my son or my stepchild or my wife or whatever. they are not trying to trick anybody. they don't really see that it is a problem. but i am telling you it is easy to do. i wanted to bring that point out, which i thought your talk raised. ike to return to this point david raised, and it's been illuded to before, let me call them the innocent bystanders or third parties where the research project or social networks occurs, it's the problem of who protects the third party. if you want to be the full monte, okay. but if it also standing in for me, i may be embarrassed by it.

can we have the discussion about the implications for others in the family or tribe or group with whom one is genetically affiliated. anyone? >> i just asked the question. i'm seeking help with it. i think we're seeking help with all the issues that we've raised. jonathan probably can deal with this one. >> well, actually, i remember when my son came back, i think he was in 3rd grade from his jewish day school one day. this is back in the early '90s, there was a flier directed at his mother attending to the jewish women for breast cancer trial. and i thought that was interesting. that was the way i heard about that study was in his backpack. i wish i had kept a picture of

it now for my talks about genetics. a few years later, and many people know story, some of the data from those early studies ended up on anti-semitic web sites because they increased risk for jewish women. so the point was, you see, they really are different. there really is something wrong with them. so i just take this as a comment on presentation to make the comment, groups stigmatization is something we're going to have to think about. beyond the family to the way in which we think about who we're connected to in various ways. >> let me ask you, group stigmataization, that's a very important to mention of what

we're looking at. but turn it around, what about the power or right or legitimacy of a groups attempt to preclude an individual's participation in one of the exercises that she described to me. that also is a possibility. >> it's a reality, actually, because there is a moratorium on genetic testing on american indian tribes now because of that. they obviously have different status. but i think, you know, your question is legitimate in the sense that should we have group consent? we kind of went about that topic before. >> let me say -- you say there's a moratorium on the testing of native american tribes. i am aware, what if an

individual in a tribe wants to participate in and insists, do you know of any instance the individual has insists and gone so far as an individual saying it's their right or whatever statutory or constitutional other basis to participate that that's one of their individual rights, have you heard of any insanses of this or anyone? >> i haven't. >> i could speak to that just a little bit. over the last 10 years, and you'll hear it a little bit this american. collected data throughout the world. we've run into this problem or question or situation whatever you want to call it a number of times. we do have a number of native americans that are in our data set. they've all been individualing opted in essentially. and it's in none of these conditions has it been challenged. i don't know if we've actually

gotten to that level where we looked to see whether the tribe could challenge it because they felt that it was up to the individual to make that decision in these cases. >> but this is a much more general question than the genetic single genetic testing question. i mean we do not have good oversight mechanisms for the benefit if the positive way, but harm is the true way for thinking about group harm of many research projects. and it's absolutely coming up in community-based participatory research. we don't have good regulations or common rule doesn't address it. this is something that i think we have to take on proactively as an issue well beyond the genetics -- >> it's much broader than

genetics too. in my area of work, i practice environmental law. the stigma attached to persons living who drunk the water or breathe the air on your site for a generation or so and they feel like they have -- they are tainted by that community experience and then researcher and others want to address their situations. and that leads you to the same problems, and it has nothing to do with genetics. >> i do want to go back to one comment that you made, tim, in passing that the uk is now protecting the ability of parents to enlist their children for genetic testing and that that should -- they should wait or one must wait until and i'm

not sure if there is true or not, must wait until they are at an age of consent. and this is a protection that i think we would do well to think about on this side of the atlantic. >> it's not a requirement, it's a view that is out there on consultation. i think -- and in the discussion about the way that other individuals might be affected by a particular genetic test, i'm not familiar with this sort of groups a sect -- aspect of it, but i think it's important to distinguish between the single gene disorders and that is more than on the part of the testing companies that are familiar with or carrying out. so for single gene disorders, clearly if one individual of the family have tested with this and are familiar, i think we'll have

well worked out mechanism of dealing with it. but if one family member in the context is found to have or be a carrier, then that have impact on the family members who may or may not want to know and the protection that is afforded by g.i.n.a.. it's very important for them. i think for the children. so testing single gene disorder, the view that i've hear clinical geneticists saying if there is no treatment, then there is no reason for the child to be tested until they have the ability to make that consent for themselves. i think geneticists apply the same argument. i view it both as the situations as being completely different. and i record having to follow

that application for a research project. an institutional review essentially, for a gene expression microdatabase. and the review board completely misunderstood what we were wanting to store information for. and they treated this information, which was gene expression data, as being a serious and worrying about the single gene disorder. i think there's a misunderstanding here. i think as far as the genetic testing for children is concerned, the recommendation or the proposals is the children should be able to make up their own mind. if we view this as an adventure which is outside, we don't quite know where it's going to end. and routine sequencing might become if it was available for

$1,000, then i think what has to say or how are the children going to be treated? and should they -- should their parents be allow to test them? i think i would describe to them the view. actually, the children need, the test need to be deferred until the children can make up their own mind. >> two comments, first is around the testing of minors. i think one of the things that has made genetics unique has been that from one day we did not test minors. we felt very strongly against offering this type of testing to minors, especially for adult-onset diseases. as we start to broaden and think about where the field is going and the ages on onset, i've had a summer of parents and physicians come to me and say, why can't i test my parent. i want to know about these risk factors for type ii diabetes and

breast cancer, since there's different risk factors around weight. how do you start to think about a construct for rolling out genetic information across the life cycle? and this is something that we're actively thinking about while maintaining that you cannot test minors for the types of information we're currently testing for. we're actually starting to investigate some sort of ideally public, private collaboration to start to investigate at what point is it relevant and appropriate and what does the informed-consent progress -- process looks like? i think there are a lot of questions that need to be addressed that we are thinking about that we haven't figured out at this stage. the second thing is getting back to the original question, when you have this information it is

genetic, it is inherently going to impact family members and groups. traditionally around any counselors at muesli had great decision -- discussions about how to share in permission with at risk family members. we were talking about the disease markers and the real struggle that we have is with the general consumer, client, patient understanding of risks and trying to explain the spectrum. because many think that genetics is genetics. it is a struggle to say that when we're talking about a dozen different markers, and you cannot figure of the probability on your own for your children. it becomes that that individual needs to test and have that

discussion. >> going back to the question about the source and of samples -- the sourcing of samples to address the chain of custody issues? do you require a statement, is that sworn? what is the nature of the custodial chain between the dna suspended and the individual who submits it? is there any constraint on my submitting anyone's dna that i wanted to cement? i am your customer but the dna might come from elsewhere? >> in terms of the system that we have set up, an individual who consents consents to there on dnase them -- submitted. they are representing themselves. i know that not everyone approach is it that way. >> supposing they are not.

how do you know? >> you do not. and that as part of -- you are talking into an illegal agreement -- your opt-in into a legal agreement. believe that it had been such an issue to date. some people do test privately and use a pseudonym. >> can i ask one comment and make one comment? the comment is akin to others that i've made. my understanding of where the field is is that the importance of clinical even if typing is deemed essential to making sense of these. and that's not a trivial thing. and it usually takes a intermedia who happens to be a health providers who's able to

do the kind of accurate detailed assessment with a patient at hand. when the companies talk about collecting and adding information about the contributors of the dna, it seems to be a disconnect there between where the academic community sits on this and where the company sit. that's the comment. the question i had is a very fundamental one. i just don't know the answer to it. so i'll direct it at professor, is there any information about all about the frequency with which an array of snips from me would be found in my kin that is the code -- cosegregation or what is it? is it likely that the array

would be entirely dependent my sister, brother, or children. if you have 1 million snips from all of the array, it will be completely unique to you. the only other person that it could be would be an identical twin. and so it's more -- well, it's at least as powerful on dna forensic fingerprinting and if someone else had access to a small number of your snips, they could identify you as being part of another pool of database. so it raises the question of we have debated about identification of an individual. and you don't need to know someone's name in order to be able to identify them. i think it is a little risk averse to take that view. because if you don't have their snips in the first place then you couldn't identify them in the database. if you have a small number, you

would be able to identify them from a large pool of individuals because they are unique to you. >> the problem with identifying third parties isn't completely new in medicine. doctors have been hearing about other people for a long time taking a psychiatric history to example. there's nothing known partial to the technical, maybe we shouldn't mystify it. there's a good case to be made that the private companies do have an obligation and do research given the fact that they are doing a lot of data that i'm going to be committed by their entities. so clearly we shouldn't go into the presumption that we shouldn't. in fact, there's a good argument to be made that they should. >> we can't leave this session without knowing what's happening since 2006 to your report. it was presented presumably to

congress and then -- >> well, we certainly have gotten a lot of phone calls and interest from people that are in this field. there's been a documently being done. we haven't done any update. but aside the slots of interest on capitol hill, there was a lot of interest. there was a fda, fdc consumer alert issued on the same day i testified warning consumers about this and educational information. that was really the result of this point. no other legislative initiatives that i'm aware of. >> what? >> which part. >> why don't you tells us which parts were illegal? >> it's authorized legal

activity to make false statements. >> we do referrals on some of these. we may have referred some of these cases to law enforcement. i'm not aware of anything that happening to anyone. some of these products that were marketed to us, they were multivitamins, and expensive, i'm not sure if it was illegal on the parking on their part especially linking the supplements to the genetic profile. if you take these you reduce your risk of getting cancer and other types of commission. >> the federal trade commission perhaps. >> yes. >> well, over the counter vitamins -- >> i'm aware that in the uk a very similar situation that rose with a company marketing and link them to genetic testing. and there was no very public

campaign by one of the group called gene watch uk, and as a result of that, the company deciding to stop marketing that particular product in the uk. >> they came to the u.s.? [laughter] >> there's been a lot of concern about the genetic testing in where there is regulation like the fda and fdc or maybe step up and provide resources to be able to go after these companies. so there is something that these companies -- >> yes, last question. >> hi, i have a comment about that. i'm a genetic counselor and director of web site called accessdna.com. we evaluate all the of the companies and allow consumers to review them and rate them. we provide information on over 1,000 genetic tests conditions and topics. we are part of that awareness.

one of the things that i have noticed in the last 6 months because i am charged with evaluating is a sharp drop in the company that is are out there. so where as last year my comparison chart had upwards of 14, 15 different companies that were selling products, i just updated the charge a month ago and i could find four or five still in business. but i'm finding more that are emerging. just a note off of that. >> i didn't catch the company name, though. >> it's accessdna.com. >> okay. we're going to come back and reconvene at 1:40. lunch is out in the hall. thank you. [captioning performed by national captioning institute] [captions copyright national

cable satellite corp. 2009] >> coming up on c-span, president obama is a weekly address and the republican addressed by john kline of minnesota. following that, an event hosted by the national archives on how bill becomes law. and then discussion of health care legislation. dollars in more than one dozen works, and national book award winning author has analyzed and critique the american public education system.

on sunday, he will take your questions live in death on noon eastern. >> coming up monday, robert redford, the founder of the sundance film festival, talks about how he got involved in environmental issues. you can see that lie monday starting at 8:00 a.m. eastern here on c-span. -- you can see that live on monday starting at 8:00 p.m. eastern here on c-span. in his weekly online address, president obama talks about his initiatives to help americans save for their retirement. he is followed by a gop a dress with john kline, the senior republican of house education and labor committee, one of the congressional panels with jurisdiction over the proposed health care legislation. yesterday we received a report that job losses had slowed dramatically compared to just a

few months ago. earlier in the week, we learn that the manufacturing sector gains in 18 months and that many of the banks that borrow money at the height of the financial crisis are now returning it to taxpayers with interest. these are only the most region -- recent signs that the economy is turning around, little comfort to those who had experienced the pain of losing a job and the previous months or the previous two years of this recession. that is why it is so important that we remain focused on speeding our economic recovery. tens of thousands of recovery projects are under way to repair our nation's roads, bridges, ports, and water rights, run away -- renovating schools. we're putting americans back to work doing the work american needs done. and mostly in private sector jobs. but even as we take aggressive steps to put people back to work, it is important to keep faith with men and women looking back on a lifetime of labor. hard-working americans deserve

to know that their efforts have resulted in a secure future, including a server -- a secure retirement. this is also led to the loss of savings. dr. robin home values has also met a drop in the value of the single largest investment most people have. the decline in the financial markets has led to the decline in the value of 401(k)'s. as a result, over the past to w o years the american people have lost $2 trillion in retirement savings. this carries a painful toll. i have heard from so many who have had to put off retirement are come out of retirement to make ends meet. i've heard from seniors who worked hard their whole lives but now in their golden years are unsure of where it to turn to pay the bills or the prescriptions or keep a home in which they raise a family. and having too little in savings leaves people not only financially unprepared for

retirement but for whatever challenges life brings. it places in jeopardy so many dreams, from owning a home to attending college. the fact is, even before this recession hit, the saving rate was essentially 0%, while borrowing rose and credit card debt had increased. many were struggling to stay afloat as jobs were scarce. that is important to remember. there also those who spend beyond their means, and more broadly, tens of millions of families have been unable to put away enough money for secure retirement for a variety of reasons. half of america's work force does not have access to our retirement plan at work and fewer than 10% of those without work for his retirement plans have one of their around. we cannot continue on this course. we certainly cannot go back to an economy based on inflated profits and maxed out credit cards, the cycles of speculative booms and painful costs, but in the short term ahead of the needs of the long term.

we have to revive the economy and rebuild its stronger than before, and make sure that people have the opportunity to save the for home or college, for retirement or a rainy day. that is essential to the effort. if you worked hard and meet your responsibilities, this country is going honor our collective responsibility to you to ensure that you can save and secure your retirement. that is why we are announcing several common-sense changes that will help families put away money for the future. first, we're going to make it easier for small businesses to do with large businesses do, allow workers automatically enrolled in a 401(k) or an individual retirement account. we know that automatic enrollment has made a big sale -- difference and participation rates by making it simpler for workers to say. that is why we are going to expand this to you. second, we will make it easier to save your federal tax refunds.

today if you have a retirement account, if you can have your refund deposited directly into your account. with this change, it will be easier for those without retirement plans to save their refunds as well. you'll be of a check the back -- a box on your tax return to receive your refund as a savings bond. third, we will make it possible for putting payments for your sick days into retirement plan if you wish. many do not have that option. the irs and the treasury department are falling -- developing a easy to follow guide in website to help people navigate through complicated waters, especially changing jobs, when you are unsure how to best continue saving for retirement. will also build on these tests by working with congress. as part of my budget, i propose ensuring that nearly every american has access tours

retirement account for his or her job. it would make it possible for workers to automatically enrolled in iras for payroll contributions, and the budget simplifies and expands the tax credit for millions of families, and matching hat of a family savings up to $1,000 per year and depositing the tax credit directly into an retire -- into a retirement account. this is a difficult time for our country but i am confident that we can meet the challenges that we face and leave behind something better, that we are back -- that we're ready to take responsibility for our future once again as a nation. i hope you enjoyed this labor day weekend with your family and friends. my larger hope and expectation is that next labor day, the economic storms we're weathering now will give way to a brighter and more prosperous times. >> hello, i am john kline from minnesota's second congressional district. i serve as the senior republican on the u.s. house education and labor committee. a panel that represents the

intersection between families, jobs, and health care. i spent a lot of time these last few weeks meeting with workers, small-business owners, healthcare professionals, and hard-working families from rural and suburban minnesota. what i hear from them is what my colleagues are hearing from americans all across this great nation. a sense of uncertainty about the health care legislation moving through congress like a runaway freight train. they ask, what will happen to my coverage and my choice of doctors? well i have to stand in line to receive treatment or get approval from someone in washington before getting and the replacement or killing a prescription for the latest diabetes medication? access to quality care in the comfort of a familiar position is not the only thing my constituents are thinking about. but trillion dollar price tags becoming almost commonplace in democratic controlled washington, american families are worried about what all the spending means for their jobs and their children and their

children's children. one report from the national federation of independent business research foundation estimated that the national health care mandate would eliminate 1.6 million jobs over a five-year period. to add insult to injury, two out of three jobs would be shed from small businesses that drive our economy. if you think that is frightening, i am sorry to say bid is getting worse. in a model, it is estimated that 4.7 million jobs could be lost as a result of held-related taxes most businesses simply cannot afford to pay. no wonder americans are scared. health care reform is being imposed upon them rather than develop with them. the potential cost are far too high. and sadly, monetary costs are only part of the picture. many are concerned that

democrats' plans may cost patients the right to see their family doctor or had any involvement in a life altering if not life-saving medical treatment. they also fear and rightly so the main cost on their job, a devastating prospect in an economy that has already lost 6.7 million jobs since this recession began. democrats have crafted this legislation behind closed doors, creating a partisan blueprint that at last count clocked in at more than 1000 pages. it is complicated. it is convoluted. it is quite simply not going to work. it is time to press the reset button. health care reform does not have to be of battle and take away coverage from americans who like what they have. it does that have to put federal bureaucrats in charge of what procedures are covered in what medication is not. our goal must be to fix what is broken in our health-care system while preserving those features that work well. we can drive down costs without sacrificing quality.

we can expand coverage without orchestrating a government takeover. if we could do all of these things without squeezing small businesses and destroying more jobs at a time when our economy needs them most. in june republicans introduced a plan that would do exactly that. our plan is designed to make health care more affordable, reduce the number of uninsured americans, and increase quality at a price for our country can afford. we will make sure that americans who like their marrow -- their health care coverage can keep it, a stark coverage -- a stark contrast to the democratic plan which the congressional budget office has said will shift millions of americans out of their current coverage. unfortunately democrats have rejected our overtures and decided to go along. but it does not have to be that way. it could be and should be a bipartisan solution. he is not too late to start over. it is not too late to do better. this labor day the folks running washington should honor merit -- honor american workers by hitting the reset button on

health care reform and stopping the government takeover that threatens american jobs. i am congressman john kline and i want to thank you for listening. >> your watching c-span, brought to you as a public service by american cable companies. up next, the national archives host an event on how bill becomes a lot. after that, a chance to see lawmakers working on health care legislation. and at 7:00 a.m. eastern, today's "washington journal." >> tuesday, president obama addresses students. the president's speech from wakefield high school in arlington, va. on the importance on persistence in success for school. we will open our phone calls for your reaction to the speech. you can see that live on tuesday starting at noon eastern here is c-span, also wants c-span.org

and hear on c-span radio. sunday on "washington journal," a look at the british health- care system. our guest is the british ambassador for left -- health and life sciences. also from the congressional research service, our report showing the civilian contractors in afghanistan and number u.s. troops. and later, an author on his book "polluted and dangerous." abandoned properties and what five cities are doing to redevelop the site of closed mills and factories. "washington journal" live with your phone calls every morning at 7:00 p.m. eastern here on c- span. >> i look at the process of how a bill becomes a public law. michael white, the managing editor of the government publication "the federal register," talks about this. this is just over an hour.

>> i like to introduce to you michael white, the managing editor of the federal register, here to talk to you about how bill becomes a public law. >> thank you. i hope i am getting a good sound level. good. it is my pleasure to speak with you all this afternoon. as a washington, d.c. native, i'm glad that i can provide you with the authentic summer experience in our nation's capital, sweltering heat, plenty of humidity. i was very pleased to be asked to present a program for the national archives anniversary. i am over the federal register, which is a component of the national archives, and have been

since our inception. i was asked to talk on how a bill becomes a law, which is a old just not -- an old chestnut, but i will look at it from our side, the executive branch, because i am not i house or senate parliamentarian and i do not want them to think i am encouraging on their territory. -- encroaching on their territory. i will start by orienting the office of the national register within the national archives. just last year will launch this new web site, federalregister. gov. this is a portal to all of our various publications on various web sites. most of our publications are found on the gpa access website.

but we also have materials on the national archives website, and we also posted certain material only on this web site. so to read all together, we have created this as a way to get to federal register publications of little more easily. today's topic is federal laws, and so we have a little error there -- a little arrow there. click on that and you get to the right place. a little bit about the office of the federal register. as you can see, it was founded in 1935. when you're behind the national archives itself. the federal register was founded in concept before it actually became a reality. after the infamous panama refining case, but where federal regulation was litigated up to the supreme court and then

found not to actually exist because it had been amended out of existence inadvertently, and could not be found as an original document -- that incident spurred the american bar association, harvard law school and others to recommend that the federal register be founded. we have fbr over there, often thought of as the father of the federal register. when he was secretary of the navy during world war i, he proposed that it be established. later on the he was not keen on the idea when he was president because like all presidents, there is some concern about opening up the government process to the general public. and the federal register is a government newspaper. fbr was considered -- there was a great deal of talk about him

being a socialist and the register might be an organ of propaganda, so nothing really changes. fbrdr was i so keen on it when t came around. new scholarship has revealed that justice brandeis was the man -- was the behind-the-scenes motivating factor. there is a wonderful article about it if you would care to look it up sunday. a couple of other milestones. the statutes at large were not always with the archives. there were produced by the secretary of state -- they were produced by the secretary of state. it was only after world war ii and the national-security apparatus was reorganized that the state department threw off its domestic duties. it really has done to this day except, say, a presidential resignation. when richard nixon resigned, he submitted a letter to henry

kissinger who was secretary of state. but the state functions, these housekeeping functions, or transfer to the national archives and the federal register after world war ii. a couple of electronic notes there, the first principle -- federal register to be electronic was in 1994. we put the entire of code of federal regulations on line in 1987. but we were updated daily and 2001. and we began digitally authenticating loss in 2007. i will say more about that later. we're very proud of the fact that we inaugurated on inauguration day daily compilation of presidential documents, which replaced the old template version, a weekly publication, and basically and prepared a daily compilation

posted the president's speech within two hours after the inauguration, and we now update it every day. this is the official publication of presidential remarks, statements, and other official documents in the federal register itself. we're switching the entire platform of all laws, regulations, to a new system called the federal digital system. we hope in the next couple of years to embrace all of the social networking tools and things like rss feeds, to notify the public to changes in regulations and laws. our objectives today, and as always -- we could easily spend three hours on the legislative process. i'm going to quickly run through thow the bill becomes a law and

toss a little more about the publication aspects, which is what we do it the federal register specifically. touch on a constitutional and evidenciary issues, and comment on the executive branch role in lawmaking. building a little deeper there -- delving a little deeper there, just before the law making itself, talk a little bit about that two different areas of making something a lot, a two different agencies handle this, and then go over serious cases and anomalies if we have time. add a few examples laid out which are more interesting than the introduction of a bill and so forth. i picked up this little cartoon, because this is kind of a deep subject.

here you see some legislation being read on the beach, and it is sure a lot easier not to follow all the ins and outs. it is quite a complex process in the congress and we're certainly not going to cover all of that today. here i expressed my apologies to the house of representatives for stealing their cartoons. this is on there website in a little different form. well, the sausage making. lawmaking has been compared to sausage making. the german chancellor otto von bismarck was credited with that statement that it is best not to look too closely at the lawmaking process because it resembles sausage making. and it is not pretty. he probably did not say that he is generally given the credit. -- but he has given the credit. the only person who can produce

a bill is a member of congress. the president cannot do that. he has had an agent introduced for the executive branch. there are four basic types of legislation. bills and joint resolutions are virtually indistinguishable. by tradition, there are different names for these actions but there are few things that specifically our joint resolutions, like amendments to the constitution that are proposed. i was here when the last one was ratified in the federal register. i oversaw bat process, the 27 amendment. it had to be introduced as a joint resolution. and that was back -- it originated 200 years ago but we will not going to bed. concurrent resolutions and simple resolutions, the two houses can come up with a concurrent resolution, maybe on a matter of procedure or a statement that they would like

to make. has to be passed by both. or they can have a simple resolution from just one house. those do not get presented to the president. now we will talk more about the bill type issue. there are pop -- private bills and public bills. private bills uzbek private parties, may be a single family, -- private bills of that private parties, may be its single family, maybe it will affect citizenship. we'll talk about the context of the schivo case. as we all know, when a bill as introduced, the members of congress try to garner support from their other members. then the big lobbying campaign kickoff. that is sometimes ashley before a bill is introduced -- actually before a bill is introduced. you will see a draft of a bill

some time circulated but that is before the official process. well, here's a picture of the hopper. and they're literally as a hopper and the house of representatives. if you look in the rules, hopper is where you put the bill in when you want to introduce it. in the senate, it is the specifically although brown box but you put it on the presiding officer's desk. and then a bill clark will sign the number, and these are basically 6 inch numbers -- sequential numbers. there is competition sometimes to get h.r. 1 in the hopper, or as dot one -- s. one. this year they were both the american in -- the american reinvestment and recovery act. and i come up with an arab iran. as a public law, it was 111-5.

another trick, the first bill to be enacted was public call 111- one, which was the salary fix for the secretary of the interior, ken salazar, the salary had to be reduced in order for him to take the office since he had voted on pay raises while he was a member of the senate. ok, so here we have many committees, 19 house and 16 senate committees they covered their -- covered different subject matters. actions get placed in a committee calendar and then get marked up in the committee, literally marked up. amendments are introduced, and they may not go anywhere. they may get tabled.

and very commonly they are referred to subcommittees. the real work takes place at a lower level. reporting a bailout -- well, a bill was reported out literally with the report attached to it. this may reflect the amendments that have been made, the discussion in the recommendations of the committee, and also a minority report -- if the minority does not agree with these recommendations, they can make an hundred and in the bill gets placed on the calendar -- they can make that known. and then the bill gets placed on the calendar. there are many different calendars to get placed under it is basically up to the majority leader in the senate and the speaker and majority leader in the house as to how the bills go on to the calendar. floor debate. again, we're generalizing year. every bill banquo's -- every

bill that goes to the floor of the house is governed by a row. it has to go through the rules committee of the house for the sporadic -- a specific parameters of the debate to be outlined aired how long it will be debated, that is all done through the rules committee. it may specify 20 hours of debate and so forth. the senate of course has unlimited debate, theoretically. there is not the same process. limited debate can lead to filibuster, and we are all hearing about that these days. the calling of the yeas or nays. i cannot watch c-span so often but i believe that the electronic voting is used in the house where as the senate has not adopted that. you hear the yeas and nays called out in the senate or the

senator was up to the front and records their vote. each house has a journal, and the votes are reflected also in the congressional record which comes out every day after the congress or one of the houses at least is in session. when a bill gets through one house it is sent to the other house. there are a couple of terms here that are important to know. one of those is in gross -- engrossed. the other one down here, and rolled. it is all very confusing. -- enrolled. one white house is the -- when one house passes the bill, it is called an engrossed bill. that is the version that goes over to the other house. that house may or may not pick up the bill. it may literally be laid on the table -- and that is the term,

meaning that it stays there, and it can be ignored. if the majority leader in the senate does not want to consider something that the house has done, that can be the end of it. there is a certain degree of comity between the houses and so they try to work those things out. once the bill is passed, there are very often differences in the two houses so those differences must be resolved in conference. each of the members of the house and senate are assigned -- are several members assigned to conference committee by their leader. that would include the majority and minority members, often. the work out those differences and the final bill has the dissent -- be sent back to it by houses of the made additional changes. and when that goes through each house again, and that is called the enrolled version.

that is just about as good as a public law because that is the version that is sent to the president. interestingly, we still talk about the parchment being sent to the white house. we no longer use goatskin for the parchment, but the paper it is very thick and resembles an apartment. -- a parchment. it has to be signed by the speaker and president of the senate. that certification will talk about later in one of the special cases that i will bring up. i don't recall which bill signing this was but this is one of our gbl access websites. when the president is signing a bill, and this idea up resentment is very important in constitutional law. -- presentment is very important constitutional law. the president will usually have a signing ceremony, maybe with

but few members of congress like you see here, or in the rose garden with some constituent groups. but the president can also take no action. recall that a 10-day law. if after 10 days, sunday excluded, the president does not do anything to the bill presented to him, then the law goes into effect. he was the on the statute books, and in distinguishable between the two, it simply says approve. night of the signed version of a 10-day law version -- neither carry up presidential facsimile. the toes get complicated because what if there are not 10-days left in the congressional session and the president does nothing? well, he can literally engage a

pocket veto by simply putting the bill aside and not returning it to the congress if he objects. but the first case is more common, whether president actually sends the vetoed bill back and specifies objections they go back to the congress with the physical objects, the bill itself, the apartment goes back. it is like a hot potato, it just traded back to the congress. interestingly enough, the pocket veto and the regular vetoes spawned a number of cases back in the 1970's and a ticket. richard nixon and gerald ford -- richard nixon sent back a number of bills and it really was not clear just what adjournment means. we all hear that congress's adjournment. along about the 1970's, congress

decided that in order to reduce the number of vetoes that the president of the opposite party in those days, richard nixon, could actually put into effect, that would appoint an agent to receive the bill while they were in internment in case the president sent the bill back. and so when you read the constitution's closely it says that if the president is prevented from returning a bill by adjournment, then a pocket veto it takes effect. so this is a little device for the congress to say that it is not impossible for him to return the bill, we have an aged, a member of congress might be there. and that led to a lot of litigation as well as the pocket veto cases later under president ford, with the president adopted of very strange hybrid version. it was like experiments with the constitution, exactly what does it mean? president ford sent back bills

with the message but claiming to have pocket be tending them at the same time. that seemed quite odd. the congress could decide how they wanted to treat debt. of course, their decision, democrats versus a republican president, was to say, we're going override this if we can. and they did so on several occasions. that went to the courts, and we got our first real hard definition of what adjournment is. the courts almost it as a hard and fast rule that it is an adjournment sine di, if it is at the end of the session, congress is adjourned. it is not the end of the session, they can appoint an agent. the constitution did not give the president the right to pocket veto a bill if congress

goes out of town for the weekend. that is not what it was intended for. later on, that became all little less clear. -- a little less clear. .

featuring polish president and other leaders. >> as congress comes back and gets ready to debate health care once again, we thought we would take this opportunity to look at some of the issues around hr- 3200, the house version of the

health care reform bill. our guest joins us to help us put context to the bill, and we will show you some of the debate that happened earlier this summer. martin von, when you look at hr- 3200, how radical is it with regard to how much change it would bring to the current health-care system? >> is a pretty far reaching system. people know this is not just in criminal nips and tucks around the edges. this is an ambitious plan. the goal is to cover all americans and provide universal health insurance, and that requires radical changes in terms of the insurance market and the revenues needed to meet that goal. >> what are some of the more significant changes to the health care system as we know it now?

>> one significant change is the one we heard about in terms of the democrats talking about a public plan to compete with private insurers. the market now is dominated by private insurers. the u.s. is not completely alone, but it is an anomaly internationally and among western nations in that sense. the effort is to create a government-run plan to compete with private insurers. that may be one of the more far reaching aspects of this. >> when you look at the entirety of the congress, or the house, 40035 members, -- 435 members, how are they reacting to it? >> a lot of nervousness, not just among republicans but

certainly in the democratic caucus itself. both in the house and senate, more moderate democrats are nervous about the plan. they are hearing from their constituents back home. not all of them are on board with the idea of a public auction. the white house is attuned to that and is sensitive to that. we are hearing that the white house, when they say things like public option, we would like it, but it is not absolutely necessary. they are attuned to the voter nervousness about that idea. it is a hard sell, particularly for the moderate democrats. >> what about the progressive democrats? >> it is sort of an issue where you push the bill in one direction and one group screams, and you push it back in the other direction, and you have someone else screaming. it is like any piece of major legislation when it is offered

like that. i think what we will see over the next several weeks is that as democratic leaders in the senate and house moved toward the senate -- toward the center to appease these moderate constituencies, we will hear a lot of yelling and screaming. i did not mean to be derogatory by saying that, but we will hear a lot of complaints from factions who are announcing their view of universal health care -- they are now seeing it watered-down. the republicans have offered their own versions of health reform, not as ambitious or with the same types of goals that the democrats have a completely remaking the system, but they have offered plans. one thing that is missing from the democratic plan that would

be an essential element of the republican plan is the whole issue of medical malpractice reform. republicans are keen to point that out. >> we have touched quite a bit in this initial conversation on the public option part of the plan. we want to show you some ways and means committee hearings from earlier this summer that deal with the public auction. -- the public option. >> it says no government run plan. i enjoyed the questioning, and i wish they were still here. let me explain why it is a stacked deck. let me explain why the public plan is really a case where they are the player and referee in the same game. let me explain why it is really virtually impossible for a public plan to compete fairly on

a level playing field with the private insurance market. four the damage is the public plan has. the public plan does not have to pay taxes. the public plan does not to hat -- does not have to have large capital reserves. the public plan does not have to account for its payroll and benefit costs of its employees. the private sector does. the public plan gets to dec take the prices it will pay for services -- speaks to dictate -- gets to dictate the prices it will play for services. let me tell you what a couple of actuarial firms who are reputed, often cited by both sides of the aisle, and who do it for a living. one group tells us in three years 122 million people will be pushed up their private health insurance. two out of every three americans will lose what they have and get

pushed on to the public plan because of all these factors, because of the cost shifting that occurs. cbo does not think cost shifting is that big of a deal. if we are underpaying hospitals by 30% with medicare, where will they make up that difference? studies show that a combined family of four will have higher premiums of $3,628 right now because of medicare and medicaid underpayments. so we will at exacerbate that underpayment. let me read a quick line from an editorial today. "the public option will not be an option for many, but rather a mandate for buying government care. a free people should be i reached at this advance of tierney." pretty harsh words. these are words that i think are

appropriate for this moment. what do we not say let's make private health insurance work? why do we not work together to make it affordable for everybody? what we not pass legislation to address the problems we have? people that do not have health insurance, people that have pre- existing conditions to cannot get it, and the fact that it costs are rising so much. we could do that together if our agenda was not to have a government takeover of health care. with the public plan, no matter what direction you look at, the destination of this bill is to have the public plan crowd out the private sector. i am looking forward to a vibrant debate on this point, but i urge my colleagues to think twice about this moment. think twice about the moment when you are going to vote for this bill, and think about what your constituents are going to

say to you in three or four years when they have lost the health insurance that they have. 80% of americans like what they have got already. let's address those americans who do not like what they've got, and not take these things away from those who like what they have. i yield. >> mr. chairman, i would oppose the amendment, and like to correct the points that my friend from wisconsin brought up. admittedly, the public plan would be tax-free, but there would be many tax -- many private plans that are not for profit, so they would not be the only tax-free. as far as capital reserves, they would be built into the premiums charged by the public plan, and will establish whatever reserves are required by the various insurance commissioners. s to payroll and benefits, they will be fully paid for by the premiums paid into the public

plan, and there will not be any government subsidize station to the plan. there will be perhaps to some participants, but they could get the same the subsidization for going into private plans. s to dictating prices, in so far as i am aware -- as to dictating prices, plans to have limited panels dictate or negotiate prices. the public plan will be no difference, except that it will create a new choice. many areas of our country dominated by one or two private insurers today. it will operate on a level playing field. it will be subject to all the market reforms and consumer protections as the private plans. it will be self sustaining, and there is one other thing that

has been a driver for innovative delivery reforms. providers or counsel for productivity, payment in since for efficient areas, improved position quality of reporting. i could go down the list. eliminate cost sharing for preventive services. these are the results of a creative, flexible, quit moving plan which -- quick moving plan which should give the public plan the emphasis that will be followed by the private plans to make good changes for the delivery of medical services. so i would urge my colleagues to vote against the amendment and allow a plan to create the kind

of competition that does not now exist in the private market, so that all americans will have the right to participate in a plan of their choice, but that there will be a choice there that will drive innovation, creativity, perform, and cost savings. >> mr. chairman, i strongly support the amendment offered by my good friend mr. ryan. this amendment goes to the heart of what we believe is one of the most serious problems with the bill before us, the so- called public option, which is really a new government-run plan that will threaten the health coverage of more than 100 million americans and put our country on the path to a government single payer system. i recognize that this is a

controversial statement. many supporters of government run plans insist they are not really trying to have a government takeover the entire system, but you do not have to take my word for it. jacob hacker it is a political scientist who is credited with developing the idea for the government run option. here is what he said about it in a speech last year. "someone once said to me, this is a trojan horse for single payer, and i said, well, it is not a trojan horse, right? is just right there. i am telling you, we are going to get there over time." common sense should tell us the same thing. the majority says that the government run plan will compete with private insurance companies. how do you compete with the federal government, when the government is also setting the

rules for the competition? there will never be a level playing field. there are any number of ways for the government plan to get an unfair advantage. the bill before us says providers will not be mandated to participate, yet the government can make it very unpleasant for those who opt out. the bill says consumers will not be forced to enroll in the government plan, yet the commissioner of the exchange can also enroll them. that is without even talking about all of that hidden subsidies that come into play whenever the government is involved in private business. make no mistake about it. this government run plan will be the camel's nose under the tent for a complete government takeover of our healthcare system.

it will mean government sets prices for physicians and hospitals well and government bureaucrats take the place of doctors in deciding what medical treatments patients will receive. it will mean sacrificing much of the medical innovations in which america is so proud to lead the world. i urge my colleagues to reject this dangerous course and passed the bryant amendment. >> mr. levin. he has to be recognized. >> i am going to yield back. we have heard those scare words before. they have been echoed for decades about government, that

government is the enemy, that it will take over, and this proposal simply will not do that. it is not a trojan horse for any thing, except to provide care for all americans, and also to provide innovation. the major reason for a public option is to drive innovation, but to drive in -- to drive a change in the way we deliver systems. you all say you want that, and yet when it comes to actually supporting something that will help bring about, you oppose it. you like to quote cbo when you

like what it may say, but you will not quote them when they say something that says you are wrong. @@@@@@@@@ )@ a,r@ b tactic. if you ask the public did they want this kind of public option, they decisively say yes. there is such an urgent need for health-care reform in this

country, and so much of a need for competition with the insurance carriers, i cannot believe anybody seriously says that the public option dick takes all the private insurance companies do not. that is simply not true, and as providers -- ask providers if insurance companies do not dictate what they were received. if they are polite, they will not laugh. you cannot scare us away from taking steps that will truly began to change this system and provide affordable health care for all americans. i urged defeat of this amendment. >> let's be clear with the legislation is trying to accomplish. we are trying to accomplish a

true national purchasing pool of exchange with a menu of health plan options for people to choose from. whether we like it or not, a large number of people in this country would like the choice of a public option in this exchange. we have been trying to do our best under this legislation and make sure that if there is a public option that moves forward, that it competes on a level playing field. it has to be self sustaining. whoever would be running the public option cannot be the one in charge of running the national exchange. an area where my friend from wisconsin may have legitimate concern is whether it makes sense to pay the reimbursement under the public option with current medicare rates. this is especially tough in areas where there has been --

why would we like in a system? there's more work that has to be done in regard to the adequacy of pegging reimbursement to current medicare rates. before this is ready for prime time, it is an issue that will have to be addressed. as far as competition is concerned, let's not fool ourselves. one of the reasons people want a public option is because there has been tremendous consolidation with the delivery of health insurance in this country. into many areas, there is not true competition right now. people would likeçó that choice, but some may not want to choose a public need a plan in the exchange that is run by private insurance companies who have different motivations, different business plans, profit motives that drive a lot of the decisions. ultimately, this is all about consumer choice. there is that recognition in the country today that there are a lot of people who would like the

choice of a public option at the end of the day, instead of having to be forced to choose a private plan as their only option in this exchange. >> i cannot believe mr. kind, that you can see charge that the organizations involved, that there can be anybody that can make it work. reform is needed in our healthcare system. some do not have access to quality, affordable health care. to many small businesses are deciding between hiring workers are paying health benefits. we need to find real solutions to these problems that hit every household and every business on main street across the country. however, i am convinced a government takeover of health care is not the solution our country wants, needs, or deserts.

i have posted numerous health care listening sessions to hear what the constituents think. no matter what health care problems that are facing, or what health care crisis they are struggling with, i heard over and over again that they do not believe more government is the answer. the problem our current health care system has is that we do not spend enough money -- we do not spend it wisely. we do not need more government interference. look at that chart. that thing is a mess. there must be nine people who tell us what kind of health care you are going to have, so what is a public plan? nobody knows. i cannot think of one instance in recent memory where the federal government getting involved in a problem make things better. once bureaucrats get involved in a situation, everything always gets worse. mr. chairman, i would like to

ask unanimous consent and -- to insert in the record the chart you are looking at that shows how much government bureaucracy is designed to make this thing work. >> mr. johnson, i want this in the record, too, but where did this chart come from? >> it comes from the joint economic committee. we hated it with a paintbrush that you can recognize. the colors are red, white, and blue. that is american, isn't it? >> there is a lot of yellow in here, but i will leave that alone. this is a very attractive chart. the artist should be commended for it. mr. pomeroy is recognized. >> let me just say i support my companion's amendment here.

>> you made that clear. >> mr. kind covered what i wanted to discuss, essentially. i want to oppose this amendment, even though i have very serious problems with the public plan as contained in the bill. the reason i do is because it does not paid fairly. pays on medicare rates, and there are portions of the country that are underpaid by medicare presently. you do not move forward constructive plea by building on a flawed foundation -- constructively. that needs to be changed. i am completely confident that this bill is not going to be the bill that ultimately goes to the president at the end of the enactment process. it is inconceivable to think that we would ultimately pass health reform rely on medicare rates for the public plan option. that is not to say that the

public plan option does not have a role if this constructed to compete fairly and effectively. to suggest that the american people are locked into the existing health and st. -- existing structure that we have would be completely at odds with the constituents i represent. they think insurance shortchanges them at every turn, and more of a competitive presence would be a good thing. whatever ends up in the final legislation needs to play fairly, and it cannot be based on insufficient medicare rates. this leaves us with the same old health-care insurance coverage we now know so well, and that is why i say we should defeat it. >> mr. davis from kentucky is

recognized. >> mr. ryan amendment to strike the government run plan from the underlying bill -- a government- run plan is simply unworkable. it does not get to the root problem of affordability or costs. it is called america's affordable health choices act. i do not know who came up with the name, but well over one trillion dollars is not considered affordable in kentucky. tens of millions of people -- he in my district, if you cannot find a provider who will see, it is worthless. the reason this bill must -- does nothing to address the core issue that some of us have been talking about for years. i not fixing the process at the core, we are going to increase costs, limit reimbursements, and reduce them. you cannot end up with anything but a rationed care system.

reform and reengineered medicare and medicare services which are not in this bill. second, true reform of the private insurance system to allow competitiveness and increase access for small business and individuals, and the thing that has not been addressed here is meaningful, medical liability reform which is necessary to free our provider so they can function and do their job. one doctor in my district said who is going to sue me now? is the government going to sue me? without all three of the things i mentioned, we fail in our shared goal. this is not about politics and partisanship. it is about human lives. we are talking about spending well over a trillion dollars to get the bill and the public plan started, and we do not know what we are going to get in the long term. we do not have the details or

the facts in front of us today because the process is being hurried along by artificially imposed timetables by people who have never worked in a professional health care world in their lives. this legislation will have generational impact. we have to take the time to consider the bill. we need to slow it down and get these practitioners from the field in here. i want to close with a quotation from an e-mail i received. we absolutely cannot reform health care in this country if we do not get a better grasp of what drives the health care costs. i am so frustrated because too many of the decision makers have little real knowledge of what needs to be addressed. is not as simple as cutting payments to hospitals or doctors. who will peel away the layers that find so much of the cost of operating a hospital?

things like hidden energy costs, malpractice costs, that create defensive medicine, and on and on. i fear for the medicare patient, as more and more doctors speak of closing their practice. other than more, in my lifetime, i do not believe there has been such an important task at hand. it is imperative that the voices of many are heard. a government-run plan will not live up to the promises made by its proponents. it will reverse -- reduce quality at a gargantuan cost. i urgyou back. -- i yield back. >> i share your enthusiasm for putting the chart in the official record. the chart was not from the joint economic committee. it is the joint economic

committee republican staff. i think this is a modest glim pse of what some of the elements are to try and rationalize a system that, if we locked this committee in this room with some of the smartest bill drafters and experts of our choosing, in a week we could not come up with a chart that would reflect the byzantine non system that faces american consumers today, a hodgepodge of costs, confusion, gaps, and inequality. what we have done here is make an initial, critical, first step to try and provide choices to people who do not have meaningful choice. i do not think this bill is done, by any stretch of the

imagination. i think it is an important step moving forward, but to pretend that somehow throwing a lot of boxes and colors on a piece of paper is somehow significant and confusing and determinative of whether or not we should have a public option, particularly for the one half of american states that have no meaningful insurance competition, where one company has speedy% or more of the market, is laughable -- has 50% or more of the market. i am pleased that the staff walked through the elements, and i hope that everybody does go ahead and correlate in pieces that are in there, because it gives you a sense of what is going to have to happen to achieve much of what there is a consensus amongst people on the committee on both sides of the

aisle. i think the bill we have before us is a start in that direction, but it would@@@@:z 11% to 14% per payroll. between two companies, they employ about 500,000 people.

i ask the ceo's what percentage of the payroll went to health care costs. they both said between 15% and 16%. i said if you could pay the government 8% and they would pick up, we do in your program and turn it over to the government program? they said in a heartbeat. this is designed to drive business owners, employers come into making economic decisions for their shareholders that wind up with employees in the government run plan. it will succeed. thank you, mr. chairman. >> why would the government possibly have a conspiracy to remove the obligation of employers to insure their employees? why would they want to do this in a heartbeat? >> is the same question i keep asking, and i do not have an answer for, but the assumption is this. most of the people writing these bills want a single payer plan.

thiss the way to get it. >> ok, ok. the chair is ready to take a vote. mr. davis is recognized. >> let me be brief. let me also say that i oppose this amendment strongly. as a matter of fact, the most important part of the legislation we arkin considering -- i want to protect all of the -- we are considering. i want to bring in those individuals who are currently out. i do not think we can have the balance we need unless we do have a public option, so i am opposed to the ryan amendment. i yield back the balance of my time.

>> i support the ryan amendment, for reasons i outlined in my question. i think the government option is poorly conceived and is a recipe for financial disaster. with that, i will yield the remainder of my time to mr. ryan. >> let me make it clear that mr. ryan can take your time and his time. >> and try and address some of the things that have been said here. i wish my friend from wisconsin were still here. he is concerned with concentration of health insurance options in america. does anybody believe that after this bill passes and becomes law, we will have more options, in addition to the public plan? we are federalizing the regulation of health insurance. let me make my case. [laughter]

we are adding new costly mandates, making health insurance more expensive. do you think the 1300 insurers out there will be able to compete in this environment? employers will be looking at a situation where the insurance they have will become more and more expensive. one study says that right now with medicare and medicaid cost shifting, is $88.8 billion a year. another study says that if this passes, the cost shifting will increase private insurance for a family plan by an average of $3,628. employers will be faced with a situation where a more people go on the public plan. the public plan under pays providers, and they make it up by overcharging private payers. cbo does not think there is much

cost shifting. everybody else to talk to does. just think about it. ask any doctor or hospital in your district, and they will tell you cost shifting occurs. employers will see their insurance going up and up at unpredictable rates. they make a choice. i can keep paying this high-cost insurance that the government tells me what i have to buy, or i can just pay and 8% payroll tax and down my employees in the same kind of help richards i have to buy them anyway. -- health insurance i have to buy them anyway. we did not have a tight labor market. we have 10% unemployment. what employer is not going to dump their employee on the public plan as soon as the price of their insurance exceeds 8% of payroll, where it already does?

the problem is this, mr. chairman. it is impossible for the private sector to be able to compete fairly with the government, with all its muscle and all of its tools. at the end of that process, we will see a situation where people will have lost their choices. employers will not be offering insurance to their employees. they will be saying, i am paying the payroll tax, you are going on the public plan. the payroll tax will be 23%. we'll have a 23% payroll tax in this country. this is not a good idea. if you come from places like where i come from, medicare under pays hospitals and doctors substantially. who is going to want to continue offering the services?

i would urge my colleagues, get rid of the public plan, and let's work at fixing the private health insurance market so that it works better. let's not take away all these insurance products the people currently enjoy. >> as we close this round, i have the deepest amount of respect for you, and it is abundantly clear what you are against. you are one of the few people that have a plan on the other side. i do hope that before we conclude this marked up, you might be able to share with us who you persuaded on your side that you have a better way. i do not care what legislation we have. it is so easy to take a shot saying this does not work, this has to happen in 2023. at my age, i am concerned that what is going to happen at the end of this week. it seems to me that somewhere

between now and the conclusion of this legislation, the chair is open to any positive thoughts that collectively might come together so that we might talk about it. it is a long way between here and the president's desk. i would like to get a vote on this, so all in favor of the bryant amendment indicate by saying aye. all opposed say no. clearly the noes have it. the clerk will call the roll. >> that was the ways and means committee debate. it was a portion of it. at the end of that, the chairman says he is open to alternatives to the public option. what are the alternatives that may be under serious consideration? >> there is one alternative that has gotten a lot of discussion

in the senate. that is to have non-profit co- ops that would be an alternative to private insurance, but would not involve a federally run plan. it is an idea that has gained a lot of currency among rural centers, in particular senator conrad of north dakota and senator grassley of iowa. it is not an idea that has followed support in the house, however. it is not really tested. there are not a lot of examples of a co-op that would work in this sort of context, and the proponents point to rural electric co-ops and that type of thing. the biggest objection is that we do not know how it would work.

there are questions of whether it would attract enough people to really function as we wanted to. >> are there any other alternatives that chairman rangel might be open to? >> aside from the co-op plan, that is the main alternative that has been discussed. >> another one of the concerns that has been raised during the debate has been the doctor- patient relationship and how that would change. in your reading of hr-3200, what do you see it would be the major changes? >> this is an issue that is very controversial. to hear republicans describe the bill and to hear democrats describe the bill, you think you are talking about two completely different bills. much of the controversy stems from new bureaucracies that the bill is creating to investigate things like how do we innovate in madison, and how we bring

more quality to treatment so that we ensure we are getting the best bang for the buck, so to speak, in terms of the treatments that are delivered. when you start talking about that, that is when republicans make the argument or get concerned that are these bureaucracies setting standards are putting forth mandates that will dictate to the doctor what kind of treatments they can prescribe and what they cannot? that is what they mean when they talk about interfering with the doctor-patient relationship. there are a number of provisions in the bill. there are new centers that are called for to study these things. for the democratic perspective, they are looking to control costs. that is what these new organizations are for, to investigate how we can deliver

treatment for less cost. when your in the minority, you have the luxury to point out things that are wrong and they could interfere with the doctor- patient relationship. a legitimately raise a question about that. >> is this where the death panels phrase comes into play? >> right, that is the catch phrase we have heard in the national media, based on a provision in the house bill on end of life counseling and what points folks in hospice care might get counseling about planning for that stage in their life. sarah palin used the term. some of the republicans that have used it sort of later backed off and said we are not claiming that some bureaucrat is actually going to dictate whether a child or an elderly

person lives or dies. that one got caught up in a little bit of hyperbole. i think it really showed the sensitivity in the electorate, the nature of how strongly people feel about being able to choose their doctor, and trusting their doctors' advice. in that sense, it is good that people are talking about that. it is certainly a legitimate concern. >> another phrase is comparative effectiveness research. what is that? >> comparative effectiveness deals with looking at different treatments and treatment outcomes, and whether one treatment consistently has a better outcome than a different treatment. to the extent that you can -- it is an area that most would agree needs more research. that is one of the things the

house bill is doing, providing funding and new avenues for that kind of research to happen so that that information will be available to doctors and to the insurance companies to say that treatment is really not effective. the idea is that you could get cost savings that way. >> the energy and commerce committee headed debate about federal employees and whether or not they should be in the middle of a doctor-patient relationship. here is part of that debate. this is about an hour in 20 minutes. >> the clerk will report the without objection, that amendment will be considered as read. >> this amendment would prevent

any federal employee or political appointee to@@@@zhf@ coverage.

i would reference particularly in cancer therapy, chemotherapy, wherein the results that the five-year survivability of prostate cancer and breast cancer is significantly less than it is in the united states under our current system. mr. chairman, that is simply because this so-called oversight group makes decisions based on costs, and not necessarily clinical effectiveness. i have no objection to the center for quality improvement to do research, hopefully scientific research, to come up with what appears to be best practices for each and every disease. but they have to take into consideration the fact that patients very, and who knows

that better than the doctor that maybe has been treating the patient for 25 years, who specializes in a particular disease, whether it is diabetes cancer, and knows that this patient is on medications that might conflict with a certain treatment that happens to be found to be the best practice by the center for quality improvement, or the least costly, but yet the doctor knows this patient should not take that drug, and that there is a better drug for him or her? when we heard last week on monday, the director of the congressional budget office talked about the fact that in

looking at this bill and the bill that was passed by the health committee in the senate, there is a bending of the growth curve in regard to the cost of health care, but is bending in the wrong direction. my fear, and the purpose of this amendment, is that when we signed up 97% of the people in this country for health insurance, universal coverage, we are not going to be able to meet those obligations. it will be like noah's ark, and you put too many people on the ark, and it may take a couple of years, but it begins to sink. so you decide you have to get rid of some of that baggage, and you began to throw people overboard. who gets thrown overboard first? it is the sickest, those

suffering from illness. i think it is very important that we do not let that happen. doctors are smart enough to understand that the center for quality improvement says what works best -- they are going to take that into consideration, but they cannot be forced, or should not be forced to practice under the dictates of some federal employees for political appointee who really has no medical background. they may be good it business -- good at business, or maybe even a former governor, but they do not practice medicine. mr. chairman, i would hope that everybody would agree with me that this amendment needs to protect these patients so that

doctors can continue to practice medicine as they see best, taking into consideration the recommendations of best practices, but not be dictated in regard to how the country. >> the gentleman yield back his time. >> i would like to speak against this amendment, and here is why. this amendment says that this would not allow any ago federal employee our political appointee" at thcenter for quality to dictate how any doctor practices medicine. this is very broad language.

this is an innovation that both sides of the aisle have nailed as a major advance in care. when doctors follow a simple checklist when doing certain procedures, a certain type of health care associated infections can be nearly eliminated, saving tens of thousands of lives and millions of dollars if implemented nationwide. if the center were to try to assist in the implementation of the check list, this could easily be construed as " dictating the practice of medicine" but the check list is exactly the prototype of what we wanted to develop. this language could prevent them from carrying out its essential task, to develop new and innovative best practices to improve the quality of health care in the united states. scientific dances, if done properly, should change the

practice of medicine -- scientific advances. we would never pass a law that said to the national institutes of health that if they develop a new therapy, doctors should not use it or could not use it. that is exactly what this amendment says. i urge my colleagues to vote against this. >> just to add to the broadness of this amendment, i would agree that we want to really think -- we do not want to deal with how doctors practice specific madison with their patients, but this is so broad, -- how doctors practice medicine with their patients. this could go to the overuse of tests are too many of the provisions we are trying to get at with this bill to improve the quality of medical practice, while at the same time making it more cost-effective.

while it looks appealing on the face, i think this is going to undermine whole legislation. i urge a no vote, and i yield back. >> i rise in support of the amendment. it is simple. nothing in this section shall be construed to allow any federal it bought -- appointee to dictate how a medical provider practices medicine. it does not say bills for medicine, researchers, it says practices medicine. if the majority is right the congress women really do not want to prescribe help doctors practice medicine, we ought to accept it. all he is attempting to do is make sure that these new

components in the legislation do not end up actually giving bureaucrats the power to tell doctors how to practice medicine. if that is not the intent of the authors of the legislation, this ought to be accepted by unanimous consent. we are going to make this point over and over and over and over and over again in this markup. most of us on the minority side believe in the marketplace. we believe in transparency. we believe in choice. we believe in letting diversity -- we are not opposed, if you want to put out a check list for best practices. the next amendment we are going to offer is one by me on transparency. you want to put out results of surgery's, and if you want to put transparency into pricing, we are all for that.

if you want to compile best practices and innovative research and make that available, you want to do internet technology, we are all for that. what we are not for, and you create so many new bureaucracies, so many new positions of potential authority and mandate in washington, where people that are not trained doctors have the ability to dictate to the medical community how to practice medicine. it is not technical language. simply, we do not want the bureaucracy created under this provision, or the presidential appointees of either party, if this bill becomes law, having any hint of the ability to

compel our medical professionals how to practice medicine. >> what he is saying is exactly my intent. the argument about not following best practices as determined by the center for quality improvement, or whatever the committee is called an whatever country, i am not opposed. i think doctors should pay attention. they should fall best practices. if it is a five step process of protocol, or 812 step protocol, i think that most physicians would follow that suggested protocol. let's say a situation where a neurologist has found that in the last three cases where he has suspected that a patient may

have a malignant brain tumor, that he ordered a cat scan, and the report was negative, there was no evidence of a brain tumor, but his clinical acumen, his gut feeling, if you will, told him that there was something wrong with this patient. so he felt like a more expensive test, an mri, should be done, and these cancers were detected and these patients had an opportunity at a very early stage to get the appropriate chemotherapy. not just to improve their five- year survivability, but hopefully to cure them. i think a doctor in that situation would be willing, if the center for quality improvement wanted to slap him are on the wrist and say we are not going to reimburse you as much, they would gladly be an

acceptance of that lesser payment if they had the continued right to make those decisions which they knew were best for their patiencts. . . you suggest that they should not develop these practices because they made some how hinder a physician from practicing medicine. that is not the case. there is nothing they would

develop that would be mandatory for say that a doctor would not be reimbursed if he did not do. the then which really is not necessary. the only thing it would do in my concern is that it is going to hinder the development of these practices. there will be -- it will interfere the practice of medicine. there is nothing in here that the mandate -- that is a mandate. i know there suggestion of that on the other side. >> i do not think any of us in opposing the amendment are suggesting that we think doctors should be told how to practice. i think the concern is, and it is ironic because the name of this construction, we are concerned that this provision could get country in a way that would end of discouraging the kind of best practices and implementation, which you agree

ought to happen anyway. i think the language of this and the potential for it to get construed such that you then create barriers@@@@@@"a#"fb@ h r @ @ @ @ @ @ @ @ @ h@ @ ,7 zbtn government-run national health system use best practices in medicine. as the guardian reported in

1998, health ministers are setting up nice designed to insure every treatment operation for medicine years is in the proven best. it will root out underperforming doctors and useless treatments. that is exactly what i hear my colleague on the other side say. what has it become? nice has become in practice a rationing board. as health care costs have exploded, even in this bill, the cbo has predicted that it will float -- in britain, it has become the heavy debt reduces spending by limiting the treatment that 61 million citizens are allowed to receive three the nhs. march comedy ruled against the use of two drugs that prolonged the lives of those with certain forms of breast and some cancers. after last year's ruling,

director noted that there is a limited pot of money that the drugs were a marginal of benefit and quite often an extreme cost and the money might be spent elsewhere. the board restricted access to the two drugs for regeneration and blindness. if they allowed this drug -- he was going blind into eyes -- they said, we will pay for the drug in one eye, but you can go without the other eye. nice limited the use of alzheimer's drugs. it includes the rejection of a drug for rheumatoid arthritis. it is a subject of protest. they even have a mass formula for doing so based on quality adjusted life year. i am telling you, folks, if we move this direction to socialize

medicine and the best intentions of the best practices, we are going to end up with a rash and health care system where people who need care will have to try to find some other country to go to. guess what? they are not out there. if you want to set up this quality board and you want them to subvert doctors and the doctor/patient riel -- relationship -- as they did in england -- go ahead. we are not want to be any part of it. >> 5 thank the gentleman for yielding. this is really straightforward. it is very fundamental. read the words of the amendment by dr. degree. -- dr. gingrey. says they may not dictate how a medical provider practices medicine. if you oppose that, then you decided that a federal bureaucrat should be able to and

can dictate how a medical provider practices medicine. if you are going to do that, then you are going to assume medical liability for every decision that she meant it. this has nothing to do with suggesting best practices. this has nothing to do with informing doctors of what is the least expensive form of care or effective if a doctor were advised that the best practice was to do what was suggested and did not do it, that would be malpractice. they could seek a remedy for that. this is not a question of it innovation. innovation can from doctors as low as government boards. the question is, do you want to put the doctor between -- put in the federal government between a patient and his or her doctor? i would suggest to you that the practice of medicine is in part

science. we can make suggestions to doctors as to what the shooter should not do. -- should or should not do. if you think we should have federal employees telling doctors how to practice medicine, and then we are abandoning medicine as it is taught in america's medical school in this country. i think the ama better listen. you are embracing that a bureaucrat is going to tell your doctor how to practice medicine. if that happens, we are giving up all form. look up the word "dictate of " it says "mandate." >> the gentleman's time has expired. who seeks recognition? >> having worked on health care

both in insurance and legislature for a number of years and the committee, the amendment is so simple that it almost seems so easy. it is probably the ultimate gotch-you amendment. i listened to the side the we have the night the kingdom with socialized medicine making decision. this is not a socialized medicine bill. it is not, no matter how much to say it is, it is not. we are taking advantage of the 60% of the folks to get their health insurance through their employer now. that is going to be continued. this is not a single payer like the uk. you brought of medical malpractice. if we do not pass this, the federal government could be the person who ultimately get sued. we are not a practicing medicine in this bill. nothing in this bill dictate

medical practice any more so than --since 1965, medicare has not all doctors how to practice. i beg you this amendment would probably could have been germain in 1965. we can go back and say in medicare action to tell somebody that they tell you what you are being reimbursed for. blue cross says that with my interest. blue cross does with my insurance. it did well as a state employee and manager of a printing business. if that is what is happening now. this bill does not allow any federal employee to do that. i would say that if you make an argument against this legislation, maybe you should have made it against medicare, which is probably the second most popular domestic issue in our country only compared to social security. this is not a national healthcare like the united kingdom. it has so many variations of it.

i get as close as you could get would be the netherlands to have a national healthcare and backed away from it. they have employer responsibility and individual responsibility. that is what is in this bill. this is such a simple amendment. it has no bearing on this bill, because it has been the to do the federal employee telling a doctor how to practice medicine. that is why the amendment should be voted down. we really do not have a federal employee provision in here or political appointee that can tell someone or a doctor how to practice medicine. i yield back my time. >> for the debate on the gringey amendment. >> this get to the heart of the debate. i take the gentlemen at his sincerity. if you read this bill, it is a bold face life. it is disingenuous to tell the

people if you want to keep your health insurance that you have and they will be able to keep a. there are perverse incentives in this bill. that is if your employer keeps a. ask your employers if you can pay and a% payroll tax or pay 15% per employee for health care. what decision will you make? they will make -- a study shows 114 million people will be shoved off with their private land and on to the government plan. employers to not want this hassle to begin with. you set up a perverse incentive not to offer health care to their employees. that is dangerous. the one thing -- way the government controls cost in health care is by rationing care. -- and/or reimbursing at dave rate less than cost. welcome to medicare and medicaid. now you have 100 million people shoved into a planet does not

reimburse at the right rate and you have a huge problem. we make up that difference by the number of people in private insurance. we are shoving 100 million people of private insurance. where does the money come from? this notion that you can tell people and say, you will get to keep it if you wanted only if your employee offers it. there is every incentive -- do not take my word for it. talk to your employers. they cannot wait for this to happen. there one to show other people off of their private insurance. -- they are going to shove people off of their private insurance. i would not ask my mother or my daughter to go into a system that i know would not allow them to survive breast cancer at the same rate that we have the ability today. that happens. i will tell you why. let me give you an example. a 19 year old persons the doctor blood in the urine.

a healthy 19 year-old playing football. they come to the conclusion that person has been charged and take a few days off. thank become a doctor said, i have watched this patient for 15 years. something is not right. something does not seem right. i want to do further tests. everyone says, do not do it. it is crazy. frankly, that woman doctor wins and the patient find out they have bladder cancer. the statistics of that for almost impossible. had that dr. not been able to act on her hind and her medical science and history with that patient, the patient would have been dead at age 26. that patient was me. i take this very seriously. when you start talking about getting involved 20 doctor and patient and this bill will do it -- to not kid yourself -- it is

the only way you can cut costs. they would have said specifically you cannot have that bladder cancer. that person should not have that treatment. that is exactly what they doing kennedy. it is what they do in great britain. if you look at the cancer statistics, and that is the general population -- in bladder cancer survivability is pretty close to 99% in the united states with treatment burda and the other two countries, it the combined is 75%. it is fitting for breast cancer in cervical cancer and skin cancer burda an. they made the trade gap. we will expect that some are young women will die of breast cancer. we will accept that. that is the trade-off they made the.

if we say we will not even draw the line in the stand, we will not allow a bureaucrat or a politician to get in the middle between the doctor and patient so they can survive. >> what the gentleman is talking about -- he is talking about the art of medicine. medicine is not an exact science. those practitioners of the art here are really good at physical diagnosis and understands patients and what signs and symptoms mean, with this bill, with this ability for the center of improvement to mandate, you take away that art from the practitioner. even more serious than that is those people in our society with chronic illnesses are going to

suffer because when the bureaucrats are in search of revenues, that is when they will deny coverage. i appreciate the gentleman for yielding. this is a good common sense amendment that lets people and practitioners continue to make the final decision. >> thank you. i would like to direct some questions to the staff about this. there are a couple of interesting words here that concern me. first, nothing in this section shall be construed. let's take the word is section. what does the word section cover? >> it refers to section 931 of the public health service act.

>> it covers the whole act? >> no, certification. it is@@@@@ @ @ @ @ @ @ @ @ @ @ d >> it could be the administrator. it could be cms. who else could it be? >> the provision could be broadly construed as any federal

employee. that could be the director of food and drugs or director of food and drugs. >> anyone in federal government dealing with federal law would not bible to do anything to con true anything to do with a medical provider. >> that could be a doctor, a nurse? >> yes, sir. a doctor on the floor in the hospital who is going to decide whether a person would get a particular shot and the

handling. >> to the extent this could relate to food and drug, sir. you can't give this particular drug because it is unsafe. is that right? >> that could include nursing homes? >> yes, sir >> hospitals? >> yes, sir. >> could it include anything in relation to billing practices? >> i'm sorry, sir.

i don't know. >> could it relate to who is kul tied to administer a certain type of medicine. could this relate to the making of the his in this matter. >> so this virtually says, the head of c mfrp s can't address

questions like what kinds of activities are permitted to be tracks. whether or not steps are taken with regard to seeing that a patient doesn't get bed sores. isn't that so? >> to the extend that it is not otherwise provided for in this section, yes. >> i think we have a dangerous amendment hoer and it probably

nodes some maimingor redrafting. i yield back the ambulance of my time. >> thank you. over the years whether i was a senate senator in tennessee, i have always looked at the issue of quality healthcare. that is at the crux small

businesses and seniors will obtain saveings sfr medicare that will be used to offset the cost of that health plan. those seniors fear rationing. so are parents of children that need go onning i am very

grateful this amendment has come forward you cannot let a bureaucrat practice medicine and make decisions. the amendment doles with section 931 of the public health services act.

something that is toing to be more fwat will to the government. >> i want to address some of the questions this amendment would dictate how a medical providers as a result of best practice

>> it is always amusing to me when you hear the argument that dam i'd love to see someone on a pole say hey, i'd like to make gigss here from washington. i want to ask council a question. what does the mean about caps

and health insurance coverage? >> i believe other portions of the bill could not allow for and you'll -- >> right. does it not say annual and lifetime caps, it is banned. >> yes. j new 17, it is up to the secretary of. this is going to be a whole list

of private employees as well as this public plan. they make the decision. once the employer makes the decision, they make the decision which plan to pit nobody forces them in to public insurance.

>> the american medical association and they support this legislation because it is key to an effective health form. >> i'll be glad to yield to the virgin island. >> i have read this section over and over and i see nothing in there that suggests that anyone would have any authority to dictate to a provider. there's nothing in there that would suggest any support or ralti

ralting. i oppose the amendment. i think a lot of the concerns raised are really not even relevant but there's nothing in here that would even suggest -- a federal employee would get between the patient yept and their doctor. >> another colleague? >> no, no. you have time. i'd like to yield to mr. stu

pe pekt. >> if you reflect back, the big three insurance when you get sick and schmidt a prescription or you have blood in your urn, you rescind. the big throw sat there and told us no, we'll continue. the only way to solve not automatically reject americans

that are ill. >> i strike that. >> ok. thank you. jo i move to strike the last word. i want to make a note about this report. 114 million americans 2 h 3 with insurance today won't have a maul business today. i can't run a calculation that makes sense for a small employer to run healthcare the way this is drafted. health insurance costs are probably 12 per

probab employers will make tough choices, especially in a down economy. they are faced with a mandate or if they go along, it requires them to provide health insurance to the family and the 12% yee and a >> to pay 75% for the employee and 60 something% for the family. if they are not doing family

coverage now. you are destroying the healthcare opportunity out there today. everybody will put the exchange. with that, i want to put. >> healthcare would have paid for it for it then. the statistic they are willing to have a higher mortality rate

with these cancers. prostate, skin, breast, plaid, cervical, moel, they are willing to have more people die from these cancers in order to cover other people. we are prying to cover 15% of the people. this gets to the heart of the bill. stay out of patient yept doctor relationships. the only way to do it they are going to have to ration care.

they do it with the best practice check list. that's we have >> would the gentleman yield to me? >> you've been asked some hypo thet cals. i can't to ask you some specifics. this is an amendment that relates to section 931. is there anything that would take away the authority of the fh. is there anything under this 9 # 1 this would change the skeem

for dang jo no, sir. is there anything in this section to change the scope of prk tis as to what a nurse or doctor can do? >> under existing scat uts, no, sir. >> if there are thorlts, they would remain unchanged. and this would not change any of the laws related to any of the shortage, would it? >> to the extent there is current law on the topics you are laying out, this would not change those statutes. >> time is expired.

host: i'm time lichled ever >> become in 1996, i introduced legislation and called it at that time christopher reid. he was a good example of people that. most people don't realize what's in their insurance policies. where this is accute late felt. it is important to note that that has been cured in this bill. members made reference to the lohan report. that was written months before

the proviegs. -- it is a refresher -- the organization is owned by united healthcare. united healthcare was the one that came before the investigations in the oversight committee and said we are not changing our practices for recision. come on. let us get our facts straight and know that we have philosophical differences. they should be debated. we need to deal with the facts. when you are talking about caps, the caps are no longer going to be extensive. the american people are going to be 1000% a better off as a result. thank you. >> thank you.

i gave some thought to debating the amendment here. since no one appeared to want to do that, maybe that will be out of character. this amendment, if i read it right, just deals with federal employees directing medical professionals. i heard someone say like that in the most americans would not like to detect aircraft that had a bad day the day before to make that decision and said their doctors. that is all this is about. there are other sections that deal with insurance companies. i think you'd find substantial interest in making the air insurance system more competitive, making it more responsive. competition has impact on price. the current system grew up to where you do not really have the kind of marketplace we could easily achieve. our concern is different than this concern. it is great. many of us believe that

government cannot compete fairly. the loewen group has been around over four decades. it is always described as a left of center healthcare group. it is never been described as conservative or right of center. it is well respected. there have been two studies. the first one said 160 million >> there have been two studies. on this bill, it said 114-125. that was two weeks ago. it was pretty close to this bill. it is hard to score this bill when you didn't necessity.

someone believes that the private competors will get smaller. this is a debate of whether a federal bureaucrat that can dictate decisions. it is not about insurance companies. it is about medical practitioners. that's not what the bill deals with. i would hope that this committee would decide that the doctor-patient relationship is more important. i support the amendment. this is about practice of medicine i don't want my doctor

to be told how to practice medicine on me or my family. >> the difference in the argument here is who is standing between patients and their doctors. we believe that insurers do time and time again. i haven't met over the phone a really bubbly pleasant, helpful euro cat.

this idea that there are bad guys in the government and good guys every place else. i appreciate you giving me some time. my doctor or doctors were in there trying to discern when was wrong with me. i have a feeling some of us on this decide. this is about doctors, patients,

doctors practicing medicine if you think they should be allowed to practice the best medicine on you and your family, vote for him. >> mr. chairman? >> i'd like to ask my good friend. isn't it true, the harm you are trying to prevent is already prevented by the stun . the 10th amendment reserves to the states all rights that

aren't spelled out. we all know that right now, the practice of medicine is regulated in all 50 states. you are trying to prohibit a practice that is already prohibited. is that correct? >> the fact that the states have that right as protected by the 10th amendment we heard that absolutely, the states could-v preempted by this section. all plans for state employees

have to cover certain mandates maybe including abortion coverage. i'd glad you asked me the question and i'll be honiest. nothing we do in a federal statute can interfear with the constitutional rights to the way we practice medicine. i want to talk to this issue of comparative message. i want to share with you a situati situation. a doctor peters came here and

developed a treatment for breast cancer. he said if they do not pass approval for this expirement al and sxrensive treatment. he told members of congress, as you look at a woman across the table, ask yourself is this would be's life worth the price of a sports car? this treatment, became concerned enough that in 1991, and he convinced the national cancer institute to fund a clinical trial to make sure that his treatment was safe.

five different clinical trials were presented in the summer of 1999 at the annual meeting. those five clinical trials found no advantages and out comes between conventional treatment and high dose chemotherapy with bone marrow transplant. what was the price? roughly 42,000 women, 30,000 in the 1990's alone were subjected to the risk of this entirely experimental treatment. 34 $4 billion was spent. they later determined that 9000 patients died not from their cancer but from the treatment that they hope to be their cure. that is why comparative effectiveness research is important. that is why it is important to make sure that we have in this bill in the unbiased language. >> we've had a lot of debate on this. >> who seeks recognition?

>> i do. i would ask you to yield two others who are seeking recognition on your site. >> what do you telling me to do? >> you are recognized. you had your five minutes. >> we talked about the 10th amendment and of that. the [unintelligible] this amendment is so simple there is not a high school kid that cannot understand here are we have taught almost an hour and a half on it. it simply says nothing in this section shall be construed to allow any federal employee for a political appointee to dictate

how medical providers practices medicine. you have read that. that is simple. is there anybody anywhere that does not understand that? you have to consider this act based on the most simple medical practice like delivering a baby. for the most severe medical practice, a coronary bypass. i just wonder who would be the most capable federal employee of health care? crawly the architects of the capital. -- probably the architect of the capital. he would be the greatest political appointee. i do not know if it is the guy that has control of the trade for all the other nations in the world. i do not think you want him telling your doctor. would you want any federal employee to tell a doctor

[unintelligible] would you want the architects of the capital telling him how to deliver a baby? i do not think you will. would you want any political appointee -- any of these that obama has appointed -- any of them to tell the late dr. how a coronary bypass ought to be run? that is of certification. nothing in this section shall be construed to allow any federal employee or political appointee to dictate how medical providers -- is that simple. i do not know why we have all this problem with all this. of course insurance companies try not to pay losses.

this is so simple that anybody in the world ought to could read this and vote aye. i yield back my time. >> a couple quick things. when i was a state senator in pennsylvania, i wrote the patient bill of rights. it deals with managed care. insurance companies were making a lot of decisions. there were people who did not practice medicine in taking over decisions. the government is going to get into the insurance business. if that which is not specifically forbidden is permitted. this specifically to forbid it otherwise it would be permitted. i hope my colleagues will be cognizant of it. the government was to get into

the insurance business. we should make sure we do not repeat the mistakes that occurred before. >> thank you. >> if we are trying to figure out consequences of this, if we are going to have this that will set of best practices, will it be setting standards and thereby having an impact upon medical liability that uses community standards? >> the provision in this section is to identify best practices for their it does not have an ability to set enforceable standards for any practitioner. nor does it have the authority to set community standards for

liability concerns. there are no enforcement provisions with in this section. it is to develop research to identify best practices. >> i think that is very helpful. none of us want anything to come between us -- a doctor and patient. that is what this is about. we do not want there to be a government board that is going to mandate the standards. you are telling me that is not in this long? >> then everybody should support the amendment. >> i'm not want to yell back to anybody else. i want to simply close with three reading this. nothing in this section shall be construed to allow any architect for any political appointment to secretary of treasury to dictate how a medical provider practices medicine. breed of then vote. -- read it then vote.

>> the gentleman's time has expired. are we ready for the vote? >> >> i want to enter into the record, this word. the number of reasons they cite. finally, the most at can. so clearly, maybe what we have touched on is a nerve year. the biggest concern many of us have expressed is looking atted

ass places that have the experience. the first thing they've gone done is ration healthcare. >> there are people that can't get access to any healthcare. >> you actually tax those people that are uninsured. the budget office says you impose $29 billion on new page 167 of the bill. you are taxing people at $19 million >> it actually shines the light on the fact that this point is going to ration care.

i'll show the organizational chart of this bill. you haven't seen this is the patie patient. they are saying remove all of these federal burrow xraft -- we had be happy to use those sxirpss. jo i want to bring up a point about louisiana medical sow sigh ilt not supporting their state. my state of georgia is feeling

the goim a did the chairman mention the support of the ama? great anothers --. let me say this as we come near a conclusion of this debate on my amendment. the arguments i have heard from the last 30-35 minutes. we can agree with ending this practice of rescission of a policy after a person is in the hospital on the operating table because of some technical

glitch. we agree with that and most of the insurance industry rye ko m kofrm. not deny al of coverage, community rating. we agree with the need for election of coverage. people employed in a small company get treated fairly. the problem is we are forevering into a new situation that we have an insurance company. that is a federal company. jo will the gentleman yield? >> i yeeltd to my friend from

arizona. >> will the gentleman yield for a yes will >> deck tating how medical providers practice medicine. is that been your experience? >> mr. chairmanman, they do that by forcing the doctors to either accept assignment or have their reimbursement cut significantly. we have medicare.

it's been in operation since 1965. does it like care. the gentleman's time has expired. let's proceed to the vote. all those in favor of the amendment say arch aye. >> subject to a lot of debate this fall. joining us to put some context to this bill is martin von. we have talked about the

politics of this bill. i want to talk about the surtex of the provision. >> the house has a lot of new costs

>> my understanding is the change will be made. unless it is made pretty clear she is coming from the heart level. >> what is the important answer of the relationship of chairman pelosi? jo she's had her hands full of bringing these three chairman that come from different backgrounds themselves and

jurisdicti jurisdiction al interests. from the get go on this, that has worked out pretty well without tomb problems. it is the house of representatives, the way the house rules are structured. there's a little easier way to get through. this are differences in those bills which will have to be

resolved. the bulk of the work is for committees to sit down and resolve this. >> for example, the waxman bill has a little different spin on the public option. this is based on the doctors and hospitals reimbursed.

in the ways and mowns, it's paid to hospital rates. >> we talked a bit on high incomes. come ert had a debate this summer. >> since this amendment. mr. chairman, under the pending bill, there is a tax on american citizens. if this still goes no effect,

this would be an immediate tax on those. this would be a 1.5% tax and over $1 million, there would be a 5.4 peshsz s%. those would double if it shows certain saveings would not occur.

the affect of the barton amendment if adopted, only those sit sdeps that make over $1 million would have the taxes increased by this surtax. this is the $1 million taxpayer

e . my home state of oregon would have the second highest income rate in the world. and sleaze state because we are having to build a whole new bridge so that -- for mr. tensleensley's state, because we having to build a new bridge to the people can move to washington -- two or injured -- two or yen. i will be supporting the domenick amendment. -- i will be supporting the gentleman's amendment. >> i yield back i am not sure -- i yield back.

>> i am not sure how mr. darden is trying to create jurisdiction over this issue -- mr. boorstin is trying to create jurisdiction over this issue. but the basic problem i see is that he is doing some kind of gimmick to undercut the revenue committee, and is sort of interesting that the chairman, mr. rangel, is here. the reason i oppose this amendment is that from the very beginning of this debate when president obama talked about the need for health care reform, he pointed out that a good part of the cost, the paygo, if you will, was going to be from cuts and -- in existing programs, medicare in particular. but at the same time, there was going to be a new revenue need. the reason there was going to be a need for new revenue is that in order to cover more people and provide assistance to middle income families through a subsidy, at least up front in

the beginning, a certain amount of money was going to have to be available down road as -- available. down the road, as more and more health care kids income on we save money. -- more health care kicks in, we save money. part of it would be paid for through program cuts and part of it through new revenue. i think that we would be kidding ourselves if we did not realize or acknowledge that some revenue sources is needed. if you look at a revenue source, i think that what the mint -- the ways and means committee came up with is probably the most responsible way of doing this that i can imagine. if you look at this surcharge, it only applies to the top 1.2% of all households in the united states. it would have no affect on 98.8% of all households in the u.s. those are families making

between $350,000 and $1 million. they would contribute less than 1% of annual income in order to provide access to affordable help care for all americans. i do not think that as much of a contribution when you are going to cover all of these people who have no insurance, plus a number of people who would get a subsidy to help make their insurance affordable to them. we are a community. everyone should help to a certain extent. i think this is the least offensive way of doing it. i know it is not before our committee and maybe we should not even be talking about it today. but of all the proposals out there, this is the least offensive. if you think we're going to be able to do this without some new source of income, you're kidding yourself. i do not represent a poor district. i have a lot of people who would be impacted by this, but i still think it is important to recognize that this is a good way of doing it and something has to be done. this is not all going to be paid for through program cuts.

i yield to the gentleman. >> i want to point out one thing. american citizens, taxes are going to go down as a result of this bill. [laughter] that may explainç why. because right now, your state are paying too much for health care because there is no containment. >> of the republicans are acting like british parliamentarians. [laughter] ration your mirth. >> as long as they do not act like south korean won's, i will be fine. [laughter] the cost to citizens will go down because it will not have inflated health care costs built in. the amount of uninsured that are walking into emergency rooms are going to go down, so more efficient care will be provided. the amount for cities like mine and states that have shares of medicaid are going to go down. overall, tax expenditures are going to go down, down, down and osorno on tax expenditures. the way everyone should look at this effort is that while -- is

that will the overall cost of life be reduced or go up? health care will double in the next five years. if we do not fix that, everything we have is going to go up in cost. the question is not, what part of it is going to go up. everything is good to go up a little, but everything is going to go down appreciably a lot. i welcome the study that says what the conclusion of the study will be. the fact is that health care costs are driving everything in this country to be too expensive. when you are buying a car, you're paying a tax. when you buy food, you are paying a tax. when you go to the office, you are paying a tax. we say, no, that is not a good policy and we are trying to take -- to change it. >> will the gentleman yield? >> i do not control the time, but bring it on. >> i thank the gentleman for yielding. >> the difference time has expired.

-- the gentleman's time has expired. maybe you could go to mr. blanton. >> i would like to make a couple of comments. one is that there is no study that i am aware of that indicates that there is anything that saves money or bends the cost curve. we heard the cbo testify with conclusively -- conclusively that the cost is not go down. the gentleman's guarantee that this is to contain cost is not supported by any information that i am aware of. the tax that we are talking about is a tax that absolutely false on most of the small businesses in america and that gets beyond the $200,000, $300,000 level and their tax would be impacted by this dramatically. the former chairman's amendment, the ranking members amendment, simply if it is going to be this tax, it tries to move it in an area where it does not impact